Updated on: July 3, 2025

DocScrib Review of Systems (ROS) Template with Examples

Review of Systems Template for Clinicians (With Real-Life Examples)

A Review of Systems (ROS) is a vital component of patient evaluation. It serves as an organized checklist of symptoms covering major body systems, allowing clinicians to gather comprehensive information from the patient beyond the chief complaint. Conducting a thorough ROS helps uncover hidden conditions, supports accurate diagnosis, and enhances clinical documentation—especially when powered by intelligent tools like DocScrib.

🏥 What Is the Review of Systems (ROS)?

The Review of Systems (ROS) is a systematic series of questions posed to the patient, aimed at identifying any symptoms they may be experiencing across various body systems. It is typically performed after taking the History of Present Illness (HPI) and serves as a bridge between the patient’s subjective concerns and the objective findings of the physical examination.

The ROS enables:

• Detection of additional or unrelated symptoms
• Discovery of early signs of new conditions
• Documentation compliance with billing and regulatory requirements

The goal is to avoid missing potentially important clinical information while maintaining efficiency and patient engagement.

🔢 Types of ROS (Per CMS Guidelines)

The Centers for Medicare & Medicaid Services (CMS) classifies ROS into three levels based on the depth of review:

1️⃣ Problem-Pertinent ROS

Focuses only on the system directly related to the chief complaint.

Example:

• Chief Complaint: “Cough”
• ROS: Patient reports dry cough for 3 days; denies chest pain, dyspnea, or fever.

2️⃣ Extended ROS

Covers the chief complaint system plus 2 to 9 additional systems to capture broader context.

Example:

• Chief Complaint: “Hypertension follow-up”
• ROS: Denies chest pain, palpitations (Cardiovascular), denies dizziness or headaches (Neurological), denies dyspnea (Respiratory).

3️⃣ Complete ROS

Includes 10 or more systems, often required for comprehensive annual exams, pre-op clearances, or complex assessments.

Example:

• Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, MSK, Neurological, Psychiatric.

📋 Why Use a ROS Template?

A well-designed ROS template is essential for:

✅ Ensuring Completeness: Reduces the risk of missing important symptoms.

✅ Reducing Mental Load: Provides structure and reminders for busy clinicians.

✅ Billing Compliance: Aligns with E/M documentation guidelines.

✅ Time Efficiency: Speeds up patient encounters and allows focus on key clinical issues.

✅ Improved Patient Safety: Identifies red flags early that may otherwise be overlooked.

By using DocScrib’s AI-driven ROS templates, clinicians can document these findings quickly, accurately, and in real-time.

🧩 Core Components of a Comprehensive ROS Template

A standard 14-system ROS includes the following systems and common prompts:

📝 Example: Full ROS Documentation Sample

Here’s a sample ROS documentation as it might appear in a routine wellness visit:

Chief Complaint: Annual physical exam

Review of Systems:

• Constitutional: Denies fever, chills, fatigue, recent weight changes.
• Eyes: No blurred vision, eye pain, or discharge.
• ENT: Denies hearing loss, nasal congestion, sore throat.
• Cardiovascular: Denies chest pain, palpitations, leg swelling.
• Respiratory: Denies cough, wheezing, or shortness of breath.
• Gastrointestinal: No nausea, vomiting, diarrhea, constipation.
• Genitourinary: Denies dysuria, hematuria, or urinary frequency.
• Musculoskeletal: Denies joint pain, muscle aches, back pain.
• Neurological: No headaches, dizziness, tingling, or weakness.
• Psychiatric: Denies depression, anxiety, sleep issues.
• Endocrine: Denies polyuria, polydipsia, heat or cold intolerance.
• Hematologic/Lymphatic: No bruising, bleeding, swollen nodes.
• Allergic/Immunologic: Denies seasonal allergies, hives, rashes.
• Integumentary: No new skin changes, lumps, or lesions.

🧠 How DocScrib Enhances ROS Documentation

DocScrib’s AI Medical Scribe revolutionizes ROS documentation by:

1. Listening and Capturing in Real-Time: As you conduct the ROS verbally, DocScrib transcribes and structures it automatically.
2. Auto-Formatting: Organizes patient responses system by system for immediate EHR-ready notes.
3. Customizable Templates: Allows you to adjust depth (problem-focused vs. full ROS) and personal preferences.
4. Time Savings: Reduces clinician documentation time by up to 70%.

🎯 Best Practices for Using ROS Templates

• Contextualize: Choose between focused, extended, or complete ROS based on visit type.
• Be Consistent: Use clear, concise language (e.g., “denies” vs. “reports”).
• Avoid Over-Documentation: Only document systems relevant to the visit to avoid clutter.
• Leverage Automation: Tools like DocScrib ensure accuracy without adding time burden.

✅ Key Takeaways

• The Review of Systems is crucial for comprehensive patient care and medical documentation.
• Using a structured ROS template improves efficiency, accuracy, and billing compliance.
• With DocScrib’s AI-powered tools, ROS can be documented faster, more consistently, and with less clinician stress.

👉 Download your free Review of Systems Template and discover how DocScrib can transform your patient documentation workflow today!